Bethesda Dilworth

In the surveyor’s words

From the most serious findings on record at Bethesda Dilworth, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Apr 11, 2025

  Based on observation, interview and record review, the facility failed to ensure an acceptable skin management program was maintained to prevent pressure injury development and to report changes timely to the physician. The facility failed to complete wound assessments, including assessment and documentation of the location, stage, size, wound characteristics, periwound (the area around the wound) and wound edge description for two residents. (Residents #1 and #2). In addition, the facility failed to follow their policy for wound photographs and measurements for three residents (Resident #1, #2, and #3). The facility failed to contact Resident #1's physician prior to entering an order for a treatment. […]

• Immediate jeopardy, isolatedF684Sep 17, 2021

  Based on interview and record review, the facility failed to ensure one resident (Resident #1001) out of nine sampled residents received treatment and care in accordance with professional standards of practice by failing to assess, monitor and implement interventions/notify the physician to prevent respiratory distress and [CONDITION(S)]. Prior to the resident's discharge from the hospital and return to the facility on [DATE], his/her hospital attending physician contacted the facility Director of Nursing (DON) directly and informed him that the resident required a [CONDITION(S)] machine (bi-level positive airway pressure; a type of ventilator which pushes pressurized air into the lungs to keep airways from collapsing. […]

• Actual harm, isolatedF689May 23, 2024

  Based on interview and record review, the facility failed to provide adequate supervision for one resident (Resident #1) who required staff assistance with transfers and mobility when going to bed. On [DATE], after the resident became adamant about staff putting him/her to bed, staff removed the resident from a sit to stand lift (a medical device that assists individuals with limited mobility in standing up from a seated position) and performed a 2-person assist transfer. The resident's right foot was caught under the bed during the transfer and sustained a comminuted tibial plateau fracture (a break in the lower bone below the knee that breaks into the knee joint and is displaced and not aligned) involving the medial (the bony surface on the top of the shin bone that corresponds to the… […]

• Actual harm, isolatedF600Jan 4, 2023

  Based on interview and record review, the facility failed to ensure one resident (Resident #14), who resided on a secured unit, remained free from abuse. Certified Nursing Assistant (CNA) H was observed throwing a cup of water onto the resident's face. Two additional staff members were present and did not intervene after witnessing CNA H throw water on the resident. CNA H continued to work and provided unsupervised, direct care to Resident #14, and nine additional residents after throwing water on the resident. The sample size was 14. […]

• No harm, potential for more than minimal, patternF679Jul 23, 2025

  Based on observation, interview and record review, the facility failed to ensure on-going resident centered therapeutic activities were provided to residents in the evenings and weekends as an integral part of their psychosocial well-being. In addition, the facility failed to ensure activities were offered to all residents who wished to attend (Residents #140, #155 and #99). This deficient practice had the potential to affect all residents in the facility who wished to attend activites. The sample size was 25. The census was 145 with 126 in certified beds.1. […]